Status of Newborn Health in India and Community-based Newborn Care

Framework of presentation• Global status of newborns

• Causes of neonatal deaths

• Significance of newborn deaths

• Status of newborn in SEAR

• Status of newborn in India

• Determinants of newborn health

• Essential newborn care

• Community practices

• NFHS III findings on newborn care practices

• Example: Gadchiroli model

• GOI initiatives

• References

Global status of newborns• Perinatal and neonatal ill health in 2000 consisted of 7

million perinatal deaths (4 million still births and 3 million early neonatal deaths) and 1 million late neonatal deaths

• Globally burden of LBW infants- 16% of all births; while in developed countries (5-7%)

• Challenges in addition to this are bad practices in the community.

• Reductions in perinatal mortality • preventive care before pregnancy,

• improved ANC that includes birth plans and emergency preparedness,

• skilled attendance during childbirth and

• refocused postpartum care for the mother and the baby.

Significance of newborn deaths: IndiaSignificance of newborn deaths: India

Day Under 5 child deaths%

Day 1 20

Day 3 25

Day 7 37

Day 28 50

ICMR Data:2003

Status of Neonatal Health in SEAR

Sr. No.

Country NMR 2000 NMR 2004

1 Bangladesh 36 36

2 Bhutan 38 30

3 Democratic peoples of Korea

22 22

4 India 43 39

5 Indonesia 18 17

6 Maldives 37 24

7 Myanmar 49 49

8 Nepal 40 32

9 Shri Lanka 11 8

10 Thailand 13 9

11 Timor East 40 29

Source: www.who.int/whosis/database

Sr. no.

Type of mortality

Mortality rate

India Maharashtra

1 Neonatal mortality

39 31.8

2 Post Neonatal mortality rate

18 5.7

3 Pere natal mortality rate

48.5 35.8

4 Infant mortality rate

57 37.5

5 Child mortality rate

18 9.5

6 Under 5 mortality 74 46.7

Early Childhood Mortality Rates

Source: NFHS III 2005-06

Early Childhood Mortality Rates for the Five-YearPeriod preceding the Survey, NFHS-1, NFHS-2, and

NFHS-3

Neonatal and post neonatal mortality Year preceding the survey Neonatal mortality Post neonatal mortality

Urban

0-4 28.5 13.0

5-9 35.9 18.8

10-14 34.6 18.1

Rural

0-4 42.5 19.7

5-9 53.9 24.2

10-14 57.5 28.1

Total

0-4 39.0 18.0

5-9 49.3 22.8

10-14 51.3 25.3

Neonatal mortality rate has decreased by 12 deaths per 1,000 live births (from 51 to 39), Post neonatal mortality rate has decreased by 7 deaths per 1,000 live births (from 25 to 18),

• In both the neonatal and post neonatal periods, mortality in rural areas is about 50 percent higher than mortality in urban areas.

• In the neonatal period, the decline in mortality was slightly faster in rural areas (26 percent) than in urban areas (18 percent).

• it is possible to stratify states and divisions –1. with very high (above 50/1000 NMR)

2. high (35-50/1000 NMR)

3. moderate (20-34/1000 NMR)

4. low (less than 20/1000 NMR

Socioeconomic Determinants Back ground characteristics Neonatal mortality Post neonatal mortality

Education of mother

No education 45.7 24.0

12th or more 19.6 6.3

Religion

Hindu 40.3 18.2

Muslim 34.1 18.2

Christian 31.5 10.1

Buddhist/neo Buddhist 43.0 9.8

Caste -SC 46.3 20.1

ST 39.9 22.3

OBC 38.3 18.3

Other 34.5 14.5

Wealth index-lowest 48.4 22.0

Middle 39.3 19.1

Highest 22.0 7.2

Demographic Determinants Demographic characteristics

Neonatal mortality Post neonatal mortality

Child’s sex

Male 33.0 10.7

Female 23.4 15.7

Mother’s age at birth

<20 30.5 13.8

20-29 28.4 12.6

Birth size

Very small 91.4 37.2

Small 42.1 19.8

Average or Larger 32.3 16.2

It was found that as the birth interval decreases , both neonatal and post neonatal mortality increases.While, it is less in first order child than the child having order more.

Essential newborn care

• Ante natal care (providers contact/visits)» TT immunization

» IFA

» t/t of RTIs/STIs

» Malaria prophylaxis

» Birth preparedness

• Labour & delivery care (Skilled attendance)» Clean delivery

» Prevention of hypothermia

» Immediate breast feeding

» Prophylactic eye care

• Postnatal care (providers contact/visits)» Exclusive breast feeding

» Warmth

» Hygiene, Cord care

» Immunization

Special care

Maternal and fetal complications

•Prevention of mother to child transmission of HIV

•M/M or referral of obstetrics & neonatal complications

Infection, malformation, and other problems

•Antibiotics

•Supportive care

•ART if in needReferral if necessary

Low birth weight•Special warmth , KMC

•Hygiene, Cord care

•Assisted feeding, if necessary

Birth Asphyxia•Resuscitation

•Post resuscitation care

•Referral if necessary

Intervention PackagesSkilled obstetric and immediate newborn care including resuscitation

Emergency obstetric care to manage complications such as obstructed labour and hemorrhage

Antibiotics for preterm rupture of membranes#

Corticosteroids for preterm labour#

Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies

Clin

ical

ca

re

Folic acid #

Counseling and preparation for newborn care and breastfeeding, emergency preparedness

Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care

Extra care of low birth weight babies

Case management for pneumonia

Fam

ily-c

omm

unity Clean home delivery

Simple early newborn care 15 - 32%

4-visit antenatal package including tetanus immunization,detection & management of syphilis, other infections, pre-eclampsia, etc

Malaria intermittent presumptive therapy*

Detection and treatment of bacteriuria#

Out

reac

h se

rvic

es

Postnatal care to support healthy practices

Early detection and referral of complications

6 - 9%

23 - 50%NMR effect

InfancyNeonatal periodPre- pregnancy PregnancyBirth

Ante natal check ups NFHS III

Type of Ante Natal care India MH

% of women had at least one ANC

76.4 90.8

% of women had ≥ 3 ANC 52.0 75.1

% of women received ≥ 2 TT injection during Pregnancy

76.3 85.1

% of women received 1 booster TT injection during 2nd or Pregnancy after 3 years or more yr

1.5 1.7

% women received IFA tabs 65.1 80.9

% of women consumed 90 or more IFA tabs

23.1 31.4

Timings of Post natal check ups NFHS IIIBack ground characteristics

Time between delivery & first Post natal check up %

No post natal check up

< 4 hrs 4-23 hrs 1-2 days 3-41 days

Urban 45.2 8.1 7.7 2.7 34.3

Rural 20.8 3.7 4.4 4.4 66.1

Type of health care provider for PNC

Residence Doctor ANM/ Nurse

Other health provider

TBA

Urban 53.0 8.1 0.2 2.3

Rural 20.9 7.8 0.8 3.4

Initiation of breast feeding NFHS III

Characteristic Timings of initiation of breast feeding % of babies received prelacteal feeds

Residence With in ½ hr With in 1 hr With in 1 day

Urban 29.4 30.3 64.5 50.2

Rural 21.4 22.4 51.9 59.8

Sex

Male 23.7 24.7 55.5 57.3

Female 23.4 24.3 55.0 57.0

Mother’s Edu

No Education 15.9 16.7 43.1 67.5

≥ 12th std 33.5 34.6 71.6 43.4

Morbidity pattern NFHS III

Characteristic % ARI % fever % diarrhea % diarrhea with blood in

stool

Age < 6 months

6.2 11.6 10.6 0.2

Urban 5.1 14.0 8.9 0.6

Rural 6.0 15.1 9.0 1.0

Treatment sought

69.0 71.0 57.1 -

Do we have Solution ?

• A mix of community and facility-based interventions

• A mix of integrated child health approaches

• Integrated management of neonatal and child hood illnesses is proven tool

Evidence-based Interventions to Reduce Newborn Deaths

Infection36%

Sepsis/PneumoniaTetanusDiarrhea

Asphyxia23%

Other7%

Complications of Prematurity

27%

Cong. Anom

7%

Low birth weight is a significantcontributor in 40–70% of neonatal deaths.

Tetanus Toxoid Immunization of MotherClean DeliveryCord CareEarly & Exclusive BreastfeedingAntibiotics for mother and baby

Warming ResuscitationSkilled Birth Attendants

Syphilis Control Folate Supplementation

Adapted from Lancet 2005

Malaria ControlAntenatal CorticosteriodTreatment of Bacteriuria

Kangaroo Mother CareBirth SpacingMaternal Nutrition

0

20

40

60

80

100

1983 2000 1983 2000

Post-neonatal mortality

Late neonatal mortality

Early neonatal mortality

Developing Regions

Developed Regions

Source: RHR/WHO, 2003

Deaths among infants under 7 days are decreasing more slowly than among older infants

Goals of IMNCI

• Standardized case management of sick newborns and children

• Focus on the most common causes of mortality • Nutrition assessment and counselling for all sick

infants and children• Home care for newborns to

– promote exclusive breastfeeding– prevent hypothermia– improve illness recognition & timely care seeking

IMNCI-INDIA-Major Adaptations

• The entire 0-5 year period covered including the first week of life

• 50% of training time for management of young infants (0-2 months)

• The order of training reversed; now begins with management of young infants

• Reduced training duration (8 days), separate training materials for physicians & health workers

• Management now consistent with current policies of MoHFW, DWCD,IYCF,PD & NAMP

• Home-based care of young infants by health workers added

What does IMNCI not provide at all or fully

• Antenatal care

• Skilled birth attendance

• Birth asphyxia management

• Inpatient care modules for first level referral hospitals

A way forwards

• SBA is a newer strategy adopted by GOI in addition to IMNCI

• Inclusion of care at birth

Where to start?Build policy commitment & Develop a national strategy

• Interlinking the strategies to reduce neonatal mortality with related fields like Reproductive health, safe motherhood and child survival

Improve newborn health services & household practices

• Plan based on maternal and newborn health status, existing services, newborn care practices to be developed

Create demand of services

• As most of the deliveries are taking place at home so, research into attitudes and dynamics of decision making at family level to be considered and appropriate plan for corrective measures

Dahanu Experience 1987-90

• Under the Rural neonatal care project, started by Govt of Maharashtra, in Dahanu Block TBA played important role for caring the newborn

• Maintence of warm chain and resuscitation of newborn recognized as a most important intervention besides detection of LBW/ preterm baby and safe transport of such baby

• Foot length by foot print was used as indicator for referral

• Neonatal mortality rate dropped from 57.1 to 33.6

• Perinatal mortality rate dropped from 74.8 to 28.7

Conclusion: domiciliary neonatal care by TBAs supported by facilities for neonatal care at PHCs and community hospitals can influence neonatal survival in our country

Gadchiroli Newborn Case Study

• SEARCH introduced home-based neonatal care.

• VHW are trained –• provide prenatal care,

• resuscitate asphyxiated babies,

• prevent and treat hypothermia,

• support breastfeeding, and

• recognize and treat infections.

• TBA are given training and basic supplies (clean delivery kits, IFA pills, condoms).

• By the third year, there was a 62% decline in neonatal mortality, and significant declines in neonatal and maternal morbidities.

• RCH II is supporting this home-based model for rural communities.

Other studies

Bangladesh study:Effect of topical treatment with skin barrier-enhancing emollients on nosocomial

infections in preterm infants in Bangladesh: a randomized controlled trial

Use of sunflower oil or Aquaphor (petrolatum, mineral oil, mineral wax, lanolin alcohol daily for massage and found infants treated with sunflower seed oil were 41% less likely to develop nosocomial infections than controls

Lancet: Volume 365, Number 9464 19 March 2005

Nepal study:Randomized trial of the effect on birth weight of a daily multiple-micronutrient

supplement given to Nepalese women during pregnancy.

The investigators found an average increase in birth weight of 77 g and a 25% reduction in the rate of low birth weight compared with the controls who received iron and folate.

Lancet: Volume 365, Number 9463 12 March 2005